Trades Qualification Statutory Declaration

Heavy Duty Equipment Technician

This form is to be completed by the applicant.
Information provided in this form will be verified.
Unless your work experience hours were gained through self-employment, Trades Qualification applications will not be accepted if they
are only accompanied by a Statutory Declaration. Non-self-employed applicants must provide at least one employer declaration from an
employer who can verify your work experience.

A. Applicant Name Name of the individual declaring their employment experience

Full name:

B. Reason for Statutory Declaration Indicate why a Statutory Declaration is required?

 Employer is no longer in business  Employment records are not available

 Applicant was self-employed (references required)  Employer will not complete Employer Declaration

If you have been unable to obtain an Employer Declaration from any of your employers, please indicate below all the efforts that you have
made to obtain an Employer Declaration. If sufficient evidence of steps taken is not provided, the application may not be approved.

Enter the dates, title, total hours worked, and nature of employment for the
C. Work History Information period this declaration applies to.
Organization / Employer name: Business Registration Number: (self-employed only)

From (yyyy/mm/dd): To (yyyy/mm/dd): Job Title: Total Hours Worked: (only hours on the tools)

Type of Employment:  Full time  Part time  Seasonal  Self-employed  Other

Office use only: Verified -  Yes No Signature: Comments:

Trades Qualification Statutory Declaration
Heavy Duty Equipment Technician

This form is to be completed by the applicant.

Information provided in this form will be verified.

 Check the “No” box if you did not personally witness the applicant
performing the tasks in the group.
D. Declaration of Job Tasks Performed  Check the “Yes” box if you personally witnessed the applicant performing
2014 NOA the tasks at the level of a journeyperson.
Strike out any individual tasks not witnessed. example
A – Common Occupational Skills
 No
Includes: Uses and maintains tools and equipment; Performs general maintenance and inspections; Organizes work;
 Yes
Performs routine trade activities
B – Engines and Engine Support Systems  No
Includes: Diagnoses engines and engine support systems; Repairs engines and engine support systems  Yes
C – Hydraulic, Hydrostatic and Pneumatic Systems
 No
Includes: Diagnoses hydraulic, hydrostatic and pneumatic systems; Repairs hydraulic, hydrostatic and pneumatic
 Yes
systems
D – Drivetrain Systems  No
Includes: Diagnoses drivetrain systems; Repairs drivetrain systems  Yes
E – Steering, Suspension, Brake Systems, Wheel Assemblies and Undercarriage
 No
Includes: Diagnoses steering, suspension, brake systems, wheel assemblies and undercarriage; Repairs steering,
 Yes
suspension, brake systems, wheel assemblies and undercarriage
F – Electrical and Vehicle Management Systems
Includes: Diagnoses electrical systems; Repairs electrical systems; Diagnoses electronic vehicle management systems;  No
Repairs electronic vehicle management systems  Yes
G – Environmental Control Systems  No
Includes: Diagnoses environmental control systems; Repairs environmental control systems  Yes
H – Structural Components, Accessories and Attachments
Includes: Diagnoses structural components, accessories and attachments; Repairs structural components, accessories  No
and attachments  Yes

E. Applicant Signature I certify that the information I provided is accurate.

Signature: Date: (yyyy/mm/dd)

Printed name: Daytime phone:

Trades Qualification Statutory Declaration
Heavy Duty Equipment Technician

This form is to be completed by the applicant.

Information provided in this form will be verified.

F. References References must be provided for all self-employment Statutory Declaration forms.

Include with your completed Statutory Declarations the names and contact information of two people who can verify your self-employed work
experience. This may include a supplier, a former employee, a contractor in the industry, or a regular, long term client. Maximum of one
reference per category.

Each individual listed will be contacted by Apprenticeship Manitoba to verify the information provided in your application.

First Name: Last Name:

Organization/Business Name: Position/Title:

Business Phone Number: Reference Cell Number:

Relationship to Applicant: Email Address:

First Name: Last Name:

Organization/Business Name: Position/Title:

Business Phone Number: Reference Cell Number:

Relationship to Applicant: Email Address: